Snoring and Obstructive Sleep Apnea

Ans.B

The given case scenario explains the patient is suffering from obstructive sleep apnea.

obstructive sleep apnea:

• Apnoea during sleep causes hypoxia and retention of carbon dioxide which leads to pulmonary constriction leading to congestive heart failure, bradycardia and cardiac hypoxia leading to left heart failure, and cardiac arrhythmias sometimes leading to sudden death.
• Decreased oxygen availability may also result in leg edema, hypertension, morning headaches.
• During sleep apnoea, there are frequent arousals which cause sleep fragmentation, daytime sleepiness and other manifestations.

Consequences of obstructive sleep apnoea:

• Congestive heart failure/cor pulmonale

• Polycythaemia and hypertension

• Atrial and ventricular arrhythmias and left heart failure

• Attacks of angina

• Snoring spouse syndrome

• Loss of memory

• Decreased libido

• Traffic accidents

Modafinil is an FDA approved drug in the treatment of obstructive sleep apnea, shift work disorder and narcolepsy.

It is not FDA approved in the treatment of lethargy in major depression.

Ref: Sleepiness: Causes, Consequences and Treatment By Michael J. Thorpy, Pages 415-6

• Laser-assisted uvulopalatoplasty (LAUP) is an outpatient procedure that involves partial resection of the uvula and soft palate using a laser. 
• It is usually offered as a treatment for snoring or as an alternative treatment in mild obstructive sleep apnoea (OSA).
• In LAUP, the redundant soft tissue is either excised or ablated.
• It helps to avoid most of the postoperative morbidity, as well as providing a good hemostatic benefit during surgery.
• The CO2 laser is the laser most commonly used by otolaryngologists for this operation.

D i.e. Lethargy in major depression

Modafinil is not approved by FDA for treatment of lethargy in depression.

Modafinil is a novel wake promoting agent that has FDA approval for narcolepsy, shift work sleep disorder and as adjunctive treatment of obstructive sleep apnea/hypopnea syndrome.

• Modafinil is a schedule IV medication, FDA approved for treating the excessive day time fatigue of narcolepsyQ.
• (CMDT). Modafinil is now the drug of choice, principally because it is associated with fewer side effects than older stimulants and has a long half life (Harrison).
• Modafinil (200 mg, taken 30-60 min before the stant of each night shift) is approved by US-FDA for excessive sleepiness during night work in patients with shift work disorder (SWD). Although treatment with modafinil significantly increases sleep latency & reduces the risk of lapses of attention during night work in patients with SWD (Harrison).
• Pharmacological therapy for obstructive sleep apnea syndrome (OSAS) is disappointing (CMDT). Unfortunately, no drugs are clinically useful in the prevention or reduction of apneas & hyponeas. A marginal improvement in sleepiness in patients who remain sleepy despite continuous positive airway pressure (CPAP) can be produced by modafinil, but the clinical value is debatable and the financial cost significant (Harrison). CPAP and MRS (mandibular repositioning split) are the two most widely used and best endence based therapies.
• Modafinil (provigil / aleretec / modavigil) is a stimulant drug by cephalon & is approved US-Food & drug administration (US – FDA) for the treatment of narcolepsy, shift work disorder, and excessive day time sleepiness (idiopathic hypersomnia) associated with obstructive sleep apneaQ.
• Although modafinil is thought to be effective in t/t of attention defecit hyperactinity disorder (ADHD), it was rejected by FDA for use by children for that purpose. It is also used off label to treat sedation & fatigue in depression, fibrmyalgia, chronic fatigue syndrome, myotonic dystrophy, opioid induced sleepiness, spastic cerebral palsy, parkihson’s disease, Schizophrenia and cocaine addiction.

Ans. ‘A’ i.e., Sleep apnea syndrome

Modafinil is approved for the treatment of (i) narcolepsy, (ii) multiple sclerosis (to relieve fatigue), (iii) shift workers and, (iv) obstructive sleep apnea.

Snoring : Noisy breathing, a rough, rattling inspiratory noise produced by vibration of pendulous soft palate or occasionally of vocal cords, during sleep.

• Snoring indicates some obstruction in upper airway and represents a continum of the similar pathology as of Obstructive Sleep Apnea (OSA), where snoring is on one end and OSA on the other.
• Management of snoring without Obstructive Sleep Apnea.
• Uvulopalatoplasty-Laser Assisted Uvulopalatoplasty (LAUP) or Bovie-Assisted Uvulopalatoplasty (BAUP). It can be performed under Local A naesthesia in OPD. In this procedure uvula is amputated and 1 cm trenches are created in the soft palate on either side of uvula. The soft palate elevates and stiffens after healing.
• Uvulopalatopharyngoplasty- It is the M/C surgery performed for Obstructive Sleep Apnea. It is also very effective in treating snoring.

OSAHS occurs in around 1-4% of middle-aged males and is about half as common in women.

The primary treatments of obstructive sleep apnea are: weight loss in those who are overweight, continuous positive airway pressure, and mandibular advancement devices. There is little evidence to support the use of medications or surgery.

Continuous positive airway pressure (CPAP) is effective for both moderate and severe disease. It is the most common treatment for obstructive sleep apnea.

Adherence to CPAP is generally better than that to an MRS, and there is evidence that CPAP improves driving, whereas there are no such data on MRSs. Thus, CPAP is the current treatment of choice (for both moderate and severe disease). However, MRSs are evidence-based second-line therapy in those who fail CPAP.- Harrison 18/p2189

There is no proven evidence that pharyngel surgery, including uvulopalatopharyngoplasty (whether by scalpel, laser or thermal techniques) helps OSAHS patients.

Ans. D: Protruding jaw

Nasal obstruction or a recessed mandible can further exacerbate the problem

Acromegaly and hypothyroidism also predispose by causing submucosal infiltration and narrowing of the upper airway